Some diagnostic examples

Most books describe the typical features of each condition, and it is often difficult for the clinician to relate the rather dry descriptions to the particular individual in the consulting room. This section describes the diagnostic problems in five real patients as they presented to the author. They are by no means inclusive of all the situations that may arise, but are intended to illustrate the need for objective assessment in order to deliver appropriate therapy for conditions that will require the patient to continue attending for medical help over many years. The first three arrived in the clinic over a 2-week period, and show how failure to measure lung function and to evaluate that information critically led to inappropriate management, which in one case had continued for many years.

• A 56-year-old man was referred because he wanted to be considered for early retirement on the grounds of 'emphysema', which had been treated with nebulized bronchodilators for the preceding 15 years. Unusually for a man requiring high-dose therapy, he had had little time off from work as a warehouseman during the 15years. His occupational health physician was concerned because his FEV1 was 79% of predicted and this did not 'fit'. The consultant agreed that despite a long smoking history, the almost normal spirometry meant that this man had little or no respiratory limitation and that his nebulizer was entirely inappropriate. There were no clues to suggest asthma, and he was not receiving steroids in any form. Further investigation included a cardiorespiratory exercise test, which showed he was capable of a normal maximum workload. The patient was pleased that he did not have severe emphysema, but was concerned as to whether he could claim back the 15 years of charges for the drugs that he had been prescribed unnecessarily!

• A 62-year-old woman was referred to the clinic as having COPD, with an FEV1 of 60% of predicted, that had been unresponsive to inhalers or oral steroids over some months. She had ceased to smoke some 3 years before. She complained bitterly of a dry, ticklish cough and was breathless when climbing stairs at home or on going to the shops. The response to inhalers had been disappointing. On examination in the clinic, there was no wheeze on auscultation and the chest was clinically clear. On inspection of the spirometric traces, it was immediately obvious that the pattern of the trace was not obstructive; the FVC was also reduced to 60% of predicted and had been overlooked. The eventual diagnosis was a fibrosing alveolitis, possibly related to her (at that time) very mild rheumatoid disease. Inhalers were withdrawn.

• The third man was 67, had been a heavy smoker (45 pack-years), and was referred as having 'COPD that was responding poorly and should be assessed for a nebulizer prescription'. He had become progressively more limited in his ability to walk since his retirement 5 years earlier and had a productive cough, worst in the mornings. His FEV1 was markedly reduced to 0.7 L. A single dose of nebulizer in the clinic caused an improvement to 1.3 L, and after a trial of oral steroids, his FEV1 rose to 2.7 L and he described feeling 20 years younger. Although he had been symptomatic for many years, he and his doctors had ascribed the symptoms to his smoking and had never considered the diagnosis of asthma. Even on reflection in this case, there were no particular clues that could or should have made the general practitioner specifically consider asthma.

• A 60-year-old housewife complained of having experienced increased breathlessness for some years, especially when shopping and hoovering. She had become unable to join friends for bridge because she was too breathless to make the journey. She had smoked 15 cigarettes per day for 34 years and was intelligent enough to have linked this to her breathlessness, although not intelligent enough to have stopped smoking. Her FEV1 was 0.8 L and her FVC 1.9 L. A peak flow chart over 2weeks showed a low level of variability between 120 and 150L/min. She was given a trial of oral prednisolone (30mg/day) over 2 weeks and her FEV1 increased to over 1.5 L with concomitant symptomatic benefit. She stopped smoking then and there and remained well and active on inhaled steroids.

• A man of 57 was referred with a 15-year history of cough and sputum and wheezing, which had at first responded 'well' to asthma inhalers but had become progressively less responsive. He was now struggling for breath after walking 100 m on level ground. His FEV1 was just 0.6 L and his PEF flow chart was unvarying. In the previous 4 years, oral prednisolone had been added and in the previous 12months he had begun using nebulized bronchodilators. In addition, osteoporosis had been diagnosed. He insisted that he had stopped smoking. No treatment helped and he died 6 months later. The post-mortem revealed gross centrilobular emphysema, and it also emerged from a relative that he had actually continued to be a 'secret smoker' despite his denial.

Accurate diagnosis does matter. In each of the above cases, a little more care initially and an objective measurement (i.e. spirometry) could have saved time and effort for the health services, as well as being better for the patient. COPD management can be quite logical.

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